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1. A Process-based Approach to Fixing Healthcare
- Interview with Steven Spear
What can be done to fix healthcare? In this Process Excellence
Network interview, author and MIT Professor Steven J. Spear,
talks to PEX Network’s editor Diana Davis about how the
healthcare system is broken and offers his perspective on what
it will take to mend it.
PEX Network: You’ve done a lot of work on healthcare improvement, a lot of work
in the healthcare field. Is healthcare broken?
Steven Spear: It is.
PEX Network: How?
Steven Spear: The problem healthcare has, in some ways, is that it’s a victim of its own
success. What I mean by that is that, traditionally healthcare was delivered by the sole
practitioner. The reason that was the case was that healthcare science was so
unsophisticated and poorly advanced, that really, the moment of magic was the
interaction between the patient and the doctor. And so healthcare built up organizations
in support of that moment of encounter between the patient and the doctor. What
happened then, and this happened fairly recently - in the last 20, 30 years at most - is
that the healthcare sciences have proliferated. So there are disciplines now which didn’t
even exist 30 years ago. And the depth of knowledge has increased exponentially in
some of those disciplines.
So, now when you go to treat an illness, deal with a condition, treat an injury it’s no
longer the patient interacting with a sole healthcare professional, but actually within an
entire system of people – doctors, nurses, pharmacists, different types of technicians,
medical assistants, secretaries, etc. There could be dozens and dozens of people just for
primary care and it takes something really challenging like dealing with cancer, and you
could be dealing with many dozens of people over the course of treatment which could
run weeks, if not, months.
PEX Network: So would you say it became like a big corporation where you’ve got
really a siloed approach?
Steven Spear: Well, that’s exactly what’s happened. So, traditionally, doctors and
nurses also were trained separately and doctor’s work was doctor’s work and nurse's
work was nurse's work. And so you had this approach of training people within their
disciplines, within their functions and then employing them also in silos, within their
disciplines, within their functions. If you walk into a typical hospital now and look at a
directory, everything is by the silo of discipline and specialty even though the care is
provided ways which have to cross all those boundaries which separate one discipline
from another.

2. PEX Network: What’s the starting point for fixing that?
Steven Spear: Right, so I’d say there’s an internal and external starting point. The
internal starting point is for senior leadership of healthcare providing organizations to
recognize that managing functions and specialties is just part of what they need to do.
What they need to do is manage the process of care delivery and so that would start with
defining work, not just by the function and the specialist, but by the service line, so start-
to-finish, end-to-end, stem-to-stern path or trajectory that patients experience, going from
injured or ill to better and well.
PEX Network: But are there major cultural stumbling blocks to achieve that?
Steven Spear: Oh, yes, there are lots of them. From the very beginning, people are
taught within healthcare that they’re an independent professional. And you see this in
every step along the way. So, I’ll give you one example. So I was following some surgical
residents on rounds, they check on their patients at something like five or six in the
morning. And the people I was watching were all thoracic surgeons. So, to really
emphasize the silo or stovepipe approach to managing care. First the interns are
rounded to check on the patients and they report it out to the residents who report it out
on another set of rounds, so the chief resident who finally reported out to Fellows and the
attending physicians – that was within thoracic surgery.
Now we happen to be bed side at the third or fourth pass on patients. And again, that
approach makes perfect sense if you exist in a world of craft and master craft people and
professional development through mentorship and apprenticeship. So you do your work
and you get it validated and it keeps popping up so you have the attending physician
who is the master craft and sort of the Yoda of the relationship. So, we’re leaving a
patient who’s had one surgery and because it’s an older patient, after the thoracic
surgeons leave, a psychiatrist comes in because there’s some issues related to
dementia. And this attending physician and psychiatrist is followed by a Fellow and a
chief resident, residents and interns and a gaggle of little ducklings or geese following
along.
And so he does his pass on this patient and then someone else comes in and it’s an
attending physician in cardiology because she also has heart problems and circulatory
problems. So he does his pass with his Fellow and chief resident, resident, and at no
point does any of them talk to each other about the patient.
And then separate from that, there’s a whole group of nurses who are responsible for the
moment-to-moment care of this patient who are having their own set of rounds and their
own set of discussions and hand-offs across shifts not talking to the doctors. Now there’s
managing the pieces, but no one has defined a process and tried to integrate the pieces
into a coherent system.
PEX Network: It sounds to me that there are two competing concerns there - first
making sure that junior doctors aren’t left in charge of a patient on their own and,
secondly, making sure that they learn. How would you balance those competing
demands?
Steven Spear: Right. So there are a couple of things you can do here. One is this notion
that people learn a profession, set of skills through practice and then through coach
practice – that makes perfect sense. That’s how we learned how to speak, how to use a

3. fork and knife, how to ride a bicycle, swim, whatever it is. So that basic notion of learn-
by-coach-doing makes sense. And then again, with the possible exception of learning to
walk, I can’t think of a human skill we have which didn’t involve some sort of coaching.
There’s another piece to this, though. I teach at MIT and, of course, there are a lot of
science and a lot of engineering students. Our students in engineering know, I think,
from the get-go that they’re learning a skill set, mechanical engineering or electrical
engineering, aerospace engineering, whatever it happens to be, in order that they can
contribute to projects much larger than themselves. And I don’t think beyond the
freshman year they ever think that they will design anything sophisticated and complex
by themselves or with their friends just from within a department. They know, even at
that level, that they have to understand how systems of work come together because
anything they design that will finally make its way into the marketplace will be the work
across all these different specialties and disciplines. So that’s engineering.
Healthcare, they’re not trained that way - to think of themselves as deeply skilled
professionals who contribute to a system much bigger than themselves. And I’ll give you
one example of that. I have a friend, Alan, and he was complaining that he discovered at
his hospital that if a certain number of his patients develop surgical site infections in a
year, that he would lose his privilege to perform surgery at that hospital, which
essentially is his income, right. And he was complaining about how unfair that was. Now,
you and I as laypeople say, Alan, patients don’t want to get surgical site infections – isn’t
that fair? He said, well, here’s the thing – the surgery I do, maybe it runs 30 minutes, an
hour, three hours, four hours of really complex work. But that patient has been in the
system for days before I touch them, will be in the system for days, if not, weeks and
months after I touch them, and all these points of contact over these hours, days and
weeks is an opportunity for an infection to occur; for an infection to be sustained and
nurtured and grow out of control. He says, not only can’t I control that, I never even see
those things, yet I’m being held responsible.
It’d be like holding the junior engineer who’s designing a single component on an aircraft
for the performance of the aircraft as a whole, rather than what would happen in Airbus,
Boeing, Ford Toyota – holding the chief engineer responsible for the integration of the
parts into his system.
PEX Network: So, effectively, this comes back to the whole, that healthcare [as a
system] is broken. None of these parts are all working together as part of a
cohesive whole?
Steven Spear: That’s right, that’s right.
PEX Network: In other work that you've done you talk about what it takes to
become a high-velocity organization – is there such a thing or can there be such a
thing as a high-velocity healthcare organization?
Steven Spear: Absolutely. The term high-velocity organizations, refers to those
organizations which have achieved exceptional levels of performance. I didn’t call them
great companies or high-performing companies because the pattern is consistent to
most outstanding organizations in many different industries. It could be high-tech like
semi-conductors, it could be auto services. What matters is that they achieve their
position of leadership through exceptional rates of sustained improvement and internally-

4. generated innovation - the velocity of getting better leads to the point of being ahead of
the pack.
Within healthcare, what we’ve seen is that certain organizations, which have started to
take on a more mature, more sophisticated view of designing, operating and improving
systems have been able to do remarkable things: eliminate complications like patient fall,
central line infections, surgical site infections, missed medication, wrong site surgery. At
certain organizations those things have disappeared. Now, when those things disappear,
the cost of providing healthcare go way down, the cost of human suffering, financial cost
of dealing with complications, and so on and so forth.
The other thing is when you start creating systems with an eye towards what are the
parts and how they relate to each other, you lose a lot of the inefficiency of things which
are designed which don’t mesh properly. For example, when we first started this work,
which was about ten years ago, I remember being in a conference where the surgeon
says, "son-of-a-gun, I get it! We spend so much time individually creating value and we
destroy it in the hand-offs."
Well, destroying value in the hand-offs means that you have rework, you have time loss,
money lost, quality of care lost. But if you create a system and you create value and then
hand it off and someone else is adding to the value rather than having to recreate the
value, not only do you increase quality, but you reduce cost, increased capacity, so on
and so forth.
My friends who were really adamant about trying to bring system thinking - the real
discipline about designing, operating and improving systems into healthcare – they say
healthcare can handle twice the patients at half the cost.
PEX Network: Amazing. And are there specific things that some organizations are
doing that seem to really be about sending them towards this goal?
Steven Spear: Right. So I’d say there were three distinct things. One is structural; one is
dynamic; one is leadership.
The structural issue is actually starting by defining and designing systems of processes
start-to-finish, end-to-end, stem-to-stern out of the currently disconnected pieces. So, for
example, you walk into most hospitals and you’ll find there is a department of radiology,
orthopedics, orthopedic surgery, medicine, pharmacy, nursing, etc., etc. Very rarely will
you discover that there’s a service line defined for new repair as opposed to hip repair
and shoulder repair, where somebody’s actually responsible for bringing all of these
things together.
So, step one is creating some structure out of the discombobulated parts – that’s one.
Then there’s the dynamic piece which is, and it gets back to this issue of high-velocity,
that when you’re trying to design things which are complex – I think we all know this from
our own personal experience, the first time is going to be imperfect. For some reason
you get it wrong. So characteristics of the high-velocity organizations, is that when they
built process, they wrap the process in constant learning. They’re very, very attuned to
things going wrong, abnormalities which they hadn’t expected in their initial design
because this is not what we predicted; this is not what we expected. We have to figure
out why things are surprising us so they can be less surprising, more reliable, higher job
going forward.

5. So if one piece is a structural response of creating process, creating system out of parts;
the second is a dynamic response of wrapping, incorporating learning into the part of
daily work. And it’s that you treat patients, but you treat patients and learn how to treat
patients better tomorrow than you did today. So that’s the second piece.
And then there’s a third piece – the third piece is leadership. What we find both within
and outside of healthcare is that organizations which struggle, is that leaders think that
operational excellence, process excellence, system design and management is
something to be delegated away from the managerial concerns of finance strategy and
that sort of thing. The organizations which really excel make sure that process
excellence is at the C-Level of the organization, that the basic skills of how do you
design, operate, improve complex work for it has a very high velocity improvement and
innovation, that that’s a concern, a worry, a daily responsibility of the senior leadership to
resolve the structural and the dynamic issues.
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Editor’s Note: The transcript of the video interview Fixing Healthcare: Interview with
Author Steven Spear, filmed on location at PEX Week Orlando January 2011.